1. 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

2. Ramesh M. Gowda, M.D.
I have no relevant financial relationships

3. 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. (
Generally occurs in the recovery phase
The majority of patients are able to be successfully defibrillated.

4. 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.

5. EKG
ventricular fibrillation cardiac arrest

6. Clinical Presentation
He was successfully defibrillated and transferred to the nearest emergency room.
On arrival, he was awake and alert but having chest pain.

7. EKG
Electrocardiogram showed ST elevation in aVR and anterolateral ST depressions.

8. 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.

9. 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

10. Cath video
The presentation, including videos, was too large to attach (as stated in the s to and however the complete presentation was ed - 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.

11. Cath video
The presentation, including videos, was too large to attach (as stated in the s to and however the complete presentation was ed - 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.

12. Cath video
The presentation, including videos, was too large to attach (as stated in the s to and however the complete presentation was ed - 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.

13. 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.

14. Cath video
The presentation, including videos, was too large to attach (as stated in the s to and however the complete presentation was ed - 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.

15. 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.

16. 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.