The Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel 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 To elucidate the rare, yet significant, risk of sudden cardiac death during exercise stress testing. To discuss the management of a case of ventricular fibrillation arrest during exercise stress testing. The chance of these tests causing a heart attack or death is about 1 in 5,000. (https://www.nhlbi.nih.gov/health/health-topics/topics/stress/risks) Generally occurs in the recovery phase The majority of patients are able to be successfully defibrillated.

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 ventricular fibrillation cardiac arrest

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 Electrocardiogram showed ST elevation in aVR and anterolateral ST depressions.

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 CRTabstracts@gmail.com and support@abstractsonline.com) - however the complete presentation was emailed - thank you for your consideration. 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. He had a 95% distal RCa lesion also.

Cath video The presentation, including videos, was too large to attach (as stated in the emails to CRTabstracts@gmail.com and support@abstractsonline.com) - however the complete presentation was emailed - thank you for your consideration. 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. He had a 95% distal RCa lesion also.

Cath video The presentation, including videos, was too large to attach (as stated in the emails to CRTabstracts@gmail.com and support@abstractsonline.com) - however the complete presentation was emailed - thank you for your consideration. 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. He had a 95% distal RCa lesion also.

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 CRTabstracts@gmail.com and support@abstractsonline.com) - however the complete presentation was emailed - thank you for your consideration. 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. He had a 95% distal RCa lesion also.

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.