Resolution of left sided benign fasciculations following cardiac stent placement in a middle-aged Caucasian male with silent myocardial infarction after preventative screenings of cardiac calcium score: a case report

Introduction

Background

Cardiovascular disease is one of the leading causes of death in the United States (1). Current screening guidelines prioritize identifying patients at high risk for cardiac events, improving safety through lifestyle modifications, medications, or medical procedures. However, many patients with limited risk factors still experience myocardial infarctions (MIs) (2,3). It is estimated that 1 in 5 patients experience silent MIs which lack typical symptoms (4).

Cardiovascular risk is typically assessed using metrics such as age, sex, family history, blood pressure, cholesterol levels, and smoking status. Cardiovascular risk calculators predict a 10-year likelihood of developing cardiovascular disease, categorizing patients as low risk (<5%), intermediate risk (5–20%), or high risk (>20%) (5). Despite these tools, gaps remain in detecting silent or atypical presentations, highlighting the need for improved screening strategies.

Rationale and knowledge gap

Additional screenings, such as cardiac calcium scores, exercise stress tests, or routine primary care visits with cardiac risk assessments, may help identify hidden risks in patients with minimal symptoms. This case illustrates how existing guidelines may overlook individuals who later present with significant coronary artery disease. Understanding the interplay between atypical symptoms, such as benign fasciculations, and underlying cardiac conditions could inform future screening protocols and preventative strategies.

Objective

This case report highlights the unique presentation of a patient with benign fasciculations leading to the diagnosis of severe coronary artery disease. The report emphasizes the clinical significance of preventative screenings and explores the potential mechanisms linking neurological symptoms to cardiac pathology. The findings highlight the need for innovative screening approaches in low-risk populations and aim to improve early detection and risk stratification methods for silent cardiac disease. We present this case in accordance with the CARE reporting checklist (available at https://jeccm.amegroups.com/article/view/10.21037/jeccm-24-111/rc).

Case presentation

A middle-aged Caucasian male presented to his family physician in late 2022 with concerns about weight loss. The patient presented with an increased body mass index (BMI) of 30.9 kg/m². At the time, cardiac and pulmonary physical exams were normal. No chest pain, palpitations, or dyspnea were reported. At this initial visit cardiac risk factors and BMI were discussed. No significant risk factors of acute coronary syndrome (ACS) were present. Family history was significant for elevated cholesterol in father and siblings, a sister with breast cancer, pancreatic cancer in his father, and heart disease in his aunt and uncle.

One month later, the patient presented to his primary care physician with a 2-month history of muscle fasciculations and anxiety of a more severe disease presentation. An electromyography (EMG) was performed to assess nerve conduction. Normal conduction was determined, and the patient was diagnosed with benign fasciculation syndrome. Labs were drawn revealing elevated cholesterol (189 mg/dL) and low-density lipoprotein (LDL) (160 mg/dL). Due to elevated lab results the patient was started on Ezetimibe (one 10 mg tablet daily), and Rosuvastatin (one 10 mg tablet daily). Lifestyle alterations and the link between coronary artery disease, obesity, and hyperlipidemia were discussed.

At the end of 2022, the patient presented again to his primary care with increased anxiety about a recent calcium score that he obtained from a private corporation. He states that he felt something was wrong with his health but because all previous labs and tests had been normal, he felt he needed to explore other options. His cardiac calcium score was 278 (mild risk ≤100, moderate risk 100–400, severe risk 400+) (6). Electrocardiogram (ECG) revealed normal sinus rhythm with no abnormalities. Physical exam revealed no cardiac abnormalities. Repeat lab studies showed elevated LDL (104 mg/dL), normal total cholesterol (152 mg/dL), elevated cholesterol/high density lipoprotein (HDL) ratio (4.6) and low HDL (33 mg/dL). A cardiac risk assessment was performed, and the patient’s risk score was calculated at 4.7%, a low risk individual (4). Patient was referred to cardiology for further work up.

The patient presented to the emergency department a week later before his scheduled cardiology follow up. He stated that he was having chest pain to the attending physician. He later reported that he had no pain, only that “I needed them to look at my heart”. A full cardiac workup was performed, serial ECGs revealed no abnormalities (Figure 1), troponin was normal, and chest X-ray had no evidence of acute cardiopulmonary disease.

Figure 1 Electrocardiogram taken during the patient’s visit to the emergency department for “chest symptoms”.

The patient’s persistence that something was wrong led the emergency physician to order a cardiac PET scan. Imaging determined that there was an inferoseptal defect with stress, a summed (SUM) stress score of 12, and 16% ischemic burden. This study predicted that the patient was at medium risk for short-term adverse ischemic cardiovascular events.

The patient and physician determined that it would be beneficial to proceed with coronary angiography for further risk assessment. Cardiac catheterization revealed a 10-mm long lesion in the proximal anterior descending artery (LAD) with partial perfusion (80% occluded) (TIMI II flow) (Figure 2). The mid right coronary artery was mildly diseased. All other vessels showed no evidence of disease.

Figure 2 Coronary angiogram with perfusion defect of proximal left anterior descending artery.

Differential diagnoses

Anginal pain equivalent.

Treatment

A cardiac stent was placed in the severely stenotic proximal LAD. The patient was started on aspirin 81 mg daily, Prasugrel 10 mg daily, and he states that he has been compliant with his prescribed medication up to 2023.

Outcome and follow up

Patient stated that his muscle fasciculations and anxiety symptoms resolved after stent placement. Patient followed up with cardiology after 1 month with no recurrence of symptoms. Patient continued platelet therapy for 6 months, was referred to cardiac rehab, and continued his statin therapy. No other cardiac events have been reported. A graphical timeline of the case evolution is presented in Figure 3.

Figure 3 Patient’s clinical timeline displayed in a graphical view. ED, emergency department; LDL, low-density lipoprotein; LAD, left anterior descending; PET, positron emission tomography.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Discussion

Key findings

The resolution of benign fasciculations following stent placement presents an interesting intersection of neurological and cardiovascular symptoms, suggesting an underlying link between these systems. This case highlights the potential importance of considering cardiac causes in patients presenting with atypical neurological symptoms such as benign fasciculations.

Strengths and limitations

A key strength of this report is its emphasis on the utility of cardiac calcium scoring as a diagnostic tool in low-risk populations. In this case, standard diagnostic tests such as EMG, ECG, and troponin were unremarkable, highlighting their inherent limitations. ECG, while effective for detecting acute ischemic changes or arrhythmias, lack sensitivity in identifying subclinical atherosclerosis or chronic ischemia. Similarly, troponin, a biomarker of significant myocardial injury or infarction, did not elevate because no acute ischemic event had occurred. EMG, designed primarily to assess neuromuscular function, is not equipped to evaluate vascular or ischemic causes of symptoms. These diagnostic gaps emphasize the complementary role of coronary calcium scoring in evaluating low-risk patients. In this instance, a coronary calcium score of 278 prompted advanced imaging, which uncovered an 80% occlusion in the proximal LAD, enabling timely intervention. However, a notable limitation remains the absence of pre-stenting neurological evaluations, which constrains definitive conclusions about causality.

Comparison with similar research

Recent studies emphasize the preventative value of cardiac calcium scoring in asymptomatic patients. Published literature demonstrates that calcium scoring can accurately predict coronary artery disease (5) and guide early interventions, particularly in patients with atypical presentations like this case. Pathologies like Takotsubo syndrome and neurogenic stunned myocardium (7) also highlight the complex relationship between cardiovascular and neurological systems, supporting the hypothesis of the “brain-heart axis” (8).

Explanation of findings

The patient’s anxiety and repeated healthcare visits may have exacerbated his benign fasciculations, reflecting a potential neurological component. Conversion disorder is a plausible explanation, as symptoms over cardiac dermatomes (T1–T5) resolved post-treatment, aligning with theories of the “brain-heart axis” (9). However, determining if the fasciculations resulted from conversion disorder, anxiety, nerve irritation, or some other disease is no longer possible with the complete resolution of the fasciculations after cardiac stenting and no further relapse. This is a common barrier in medical practice as symptoms of multiple diseases often overlap resulting in vague differential diagnoses until further evidence can be compiled.

Implications and actions needed

This case underscores the need for broader adoption of cardiac calcium scoring in low-risk populations and calls for future studies to further explore the relationship between neurological symptoms and silent MI. Developing standardized screening protocols could prevent missed diagnoses in similar cases.

Conclusions

This case highlights the importance of cardiovascular screening for low-risk patients. Similar to colonoscopies for detecting early colon cancer, there is a need for parameters to screen for heart disease—the leading cause of death in the United States (10). Without the patient’s initiative to obtain a calcium score and persist in seeking further testing, the atherosclerotic LAD would have gone undetected. This case underscores the utility of coronary calcium scores in identifying coronary artery disease progression in atypical cardiac presentations and the importance of trusting patients’ perspectives when clinical findings are unclear. Coronary artery calcification confirms a higher likelihood of obstructive coronary artery disease (CAD), warranting aggressive risk-reduction strategies.

Patient’s perspective

In the early summer of 2022, I began feeling like there was something wrong with my health. Physically I felt fine but mentally had a feeling that something wasn’t right. I made an appointment with my primary care physician for a physical exam. I had bloodwork done and was told that everything was fine. The sense that something was wrong remained and began to amplify.

By late summer/early fall of 2022, I began having some muscle twitches and fasciculations all happening throughout my body. I went back to my primary care and had more bloodwork done to see what could be causing the twitching. I was referred to a neurologist for more testing. I had an EMG test, and I was diagnosed with Benign Fasciculation Syndrome.

The feeling like something was seriously wrong with my health continued. I visited my primary care physician and was told I was healthy, and he didn’t know of any other tests they could do because I wasn’t having any symptoms.

I recalled hearing about a medical facility where you can order full body scans and get the results. I elected to have a calcium score scan done on my heart with this company. I had the scan done in mid-December of 2022. I got the results of that scan in late December. The score was over 250 and most of the high score was in my LAD artery. The other arteries had low/normal scores.

I was able to schedule an appointment with a cardiologist for January 17, 2023. On January 3, 2023, I felt the need to go to the emergency room to get looked at sooner. At the time, I was still not having physical symptoms. I went to the ER and knew that they needed to look at my heart. I told them I was having chest pain (even though I was not). I was given an ECG, chest X-ray, and bloodwork, all came back normal. I told them about my high calcium score, and they decided to perform a PET scan. The scan had an artifact, and my LAD was not fully visible. It was determined that I needed to have an angiogram. During the angiogram it was determined I had between 80–90% blockage of my LAD. A stent was placed to open the blockage.

I was told after the procedure that the amount of blockage I had would have been deadly for me had it not been dealt with. I was glad that I was persistent in listening to the feeling that I had about my health. I was quite frustrated at the end of 2022 knowing that I needed more medical attention, but that I had exhausted all my resources through my insured health care system. I knew something was wrong but was told that I was fine. I was glad there was more testing that I could get outside of my health care network. Without that option I don’t know that I would have had my issue diagnosed and the outcome could have been much different.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at: https://jeccm.amegroups.com/article/view/10.21037/jeccm-24-111/rc

Peer Review File: Available at: https://jeccm.amegroups.com/article/view/10.21037/jeccm-24-111/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jeccm.amegroups.com/article/view/10.21037/jeccm-24-111/coif). A.B. has a contract with Leidos and the Defense Threat Reduction Agency to create a long COVID registry and study the impacts of different therapeutics. She also serves on an SBIR/STTR study section routinely and has a patent from her post doctoral work. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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