Download Ramesh M. Gowda, MD

Ventricular Fibrillation
Cardiac Arrest During Exercise
Stress Testing:
A Case Study in the Prevention of Sudden
Cardiac Death
Dr. Ramesh M. Gowda, M.D.
The Icahn School of Medicine at Mount Sinai,
Mount Sinai Beth Israel
Ramesh M. Gowda, M.D.
I have no relevant financial relationships
Learning objectives
1. To elucidate the rare, yet significant, risk of
sudden cardiac death during exercise stress
testing.
2. To discuss the management of a case of
ventricular fibrillation arrest during exercise
stress testing.
Clinical Presentation
• 71 year old male, with a history of coronary
artery disease with percutaneous coronary
intervention 4 years prior, underwent a routine
exercise stress test.
– Completed 6 minutes
– Developed significant dyspnea
• 2 mm ST depressions in the inferolateral leads and ST
elevation in aVR.
• The exercise stress test was stopped
• Upon sitting in a stretcher thereafter
– ventricular fibrillation cardiac arrest.
EKG
Clinical Presentation
• He was successfully defibrillated and
transferred to the nearest emergency room.
• On arrival, he was awake and alert but having
chest pain.
EKG
Clinical Presentation
• The exercise stress test was stopped
• Upon sitting in a stretcher thereafter
– ventricular fibrillation cardiac arrest.
• He was successfully defibrillated and
transferred to the nearest emergency room.
• On arrival, he was awake and alert but having
chest pain.
Cath video
• He underwent emergent invasive angiography,
which revealed:
– a distal left main 85% focal calcified stenosis
involving the ostial LAD
– patent stents in the proximal and mid LAD
– an 80% ostial diagonal lesion
– 100% ostial left circumflex (LCx) disease
– 95% distal RCa lesion
Cath video
The presentation, including videos, was too
large to attach (as stated in the emails to
[email protected] and
[email protected]) - however
the complete presentation was emailed thank you for your consideration.
Cath video
The presentation, including videos, was too
large to attach (as stated in the emails to
[email protected] and
[email protected]) - however
the complete presentation was emailed thank you for your consideration.
Cath video
The presentation, including videos, was too
large to attach (as stated in the emails to
[email protected] and
[email protected]) - however
the complete presentation was emailed thank you for your consideration.
Clinical Presentation
• At this time, the decision was made to consult
cardiac surgery.
– However, the patient continued to have chest
discomfort despite IV nitroglycerin, IV heparin and
integrillin bolus.
• Because of this unstable situation, urgent PCI
of left main was done.
Cath video
The presentation, including videos, was too
large to attach (as stated in the emails to
[email protected] and
[email protected]) - however
the complete presentation was emailed thank you for your consideration.
Clinical Presentation
• The patient was chest pain free at the end of the
procedure and transferred to the CCU in stable
condition.
• Because of the severity of the patient’s remaining
coronary disease, a heart team discussion was
had and coronary artery bypass graft surgery was
scheduled for the next week.
• Meanwhile, the patient was monitored in the
CCU with an intraaortic balloon pump and on
heparin and aggrastat infusion. He did well post
surgery.
Take Home Messages
• Although the risk of cardiac arrest during
exercise stress testing is small, it does exist.
• Patients who have ischemic ECGs post
resuscitation should be taken for invasive
angiography as the likelihood of an ischemic
cause is high.
• Decisions regarding revascularization
strategies should then be made with a heart
team approach on a case by case basis.