Circulation Cardiovascular Case Series

258 A 73-year-old white woman presented to a community hospital emergency department with 7 days of productive cough, dyspnea, and fatigue. Her vital signs were as follows: temperature, 99.9°F; pulse, 100 bpm; respiratory rate, 16 breaths per minute; blood pressure, 153/78 mm Hg; and oxygen saturation, 97% on room air. Her jugular venous pressure was normal; her lungs were clear; and her cardiac examination demonstrated tachycardia but no murmurs or gallops. Extremities were warm without edema. Her complete blood count was normal with the exception of a mild leukocytosis (13 000 cells/mm). Her electrolytes and renal function were normal (creatinine, 0.8 mg/dL). Her troponin T level was <0.01 ng/mL. A chest radiograph demonstrated a subtle right middle lobe infiltrate. Intravenous ceftriaxone and azithromycin were given for community-acquired pneumonia. Relevant medical history included hypertension, hyperlipidemia, and an ischemic stroke 21 months previously that resulted in residual right hemiplegia. She had no history of cardiac disease. The patient was married and lived at home with her husband, who assisted her with many of her activities of daily living. While in the emergency department, the patient became unresponsive, and ventricular fibrillation was detected on the telemetry monitor. Cardiopulmonary resuscitation was delivered for 3 minutes, and sinus rhythm was restored after 1 defibrillatory shock. The patient was subsequently intubated for airway protection and loaded with intravenous amiodarone, and an ECG was obtained (Figure 1). Hypotension ensued over the next 10 minutes, and dopamine was initiated for hemodynamic support. Requests were made to transfer the patient to a tertiary care facility with 24-hour cardiac catheterization capability. Dr Yeh: The patient’s initial presentation was consistent with possible community-acquired pneumonia. However, the occurrence of ventricular fibrillation, aborted sudden death, and ensuing shock dramatically alters the clinical priorities and calls for a rapid diagnostic and therapeutic plan. Although a number of processes, including metabolic abnormalities, drug effects (eg, QT prolongation), and noncoronary structural heart abnormalities, may be associated with ventricular arrhythmias, acute myocardial ischemia must be considered likely in this elderly patient with known cardiovascular disease. The ECG demonstrates diffuse ST-segment depressions across the precordial leads, an ominous finding consistent with a large amount of myocardium at risk. Subtle ST-segment elevation is also present in lead aVR, a finding that is classically associated with left main coronary involvement and that adversely predicts shortand long-term mortality in patients with acute coronary syndromes. There is isolated 1-mm ST-segment elevation in lead III, but this is not sufficient for the diagnosis of ST-elevation myocardial infarction because elevation is not present in ≥2 contiguous leads. Given the development of cardiac arrest and shock, she should be transferred to a facility capable of providing emergent coronary angiography, possible mechanical circulatory support, and percutaneous coronary intervention (PCI). There is no indication for systemic thrombolysis based on the ECG findings; if findings consistent with acute ST-segment elevation myocardial infarction were present, transfer for primary PCI would still be the preferred strategy if the time delay is acceptable owing to the presence of hemodynamic instability. Because of the patient’s history of stroke with residual debilitation, the high-risk nature of her presentation, and her inability to communicate while intubated, a careful discussion with the patient’s family about her desires for aggressive care is indicated. Patient presentation (continued): Phone conversations between the receiving interventional cardiologist, the emergency room physician, and the patient’s daughter revealed that the patient had been considering a code status of “do not resuscitate.” This was driven primarily by the fact that her rehabilitation course after her stroke 21 months prior was prolonged and difficult, and it had taken her nearly 1 year to become self-sufficient in performing her activities of daily living. Nonetheless, these decisions had not been finalized, and coronary angiography was ultimately pursued in accordance with the family wishes. The patient was bolused with unfractionated heparin and administered 325 mg aspirin. She was transferred to a neighboring tertiary care hospital at 1 am for emergency coronary