Serial Case Series
Percutaneous Coronary Intervention in Return of Spontaneous Circulation (ROSC) patients Caused by Ventricular Tachycardia with ST Segment Elevation Myocardial Infarction
Yudistira Panji Santosa*; Angelina Yuwono
Department of Internal Medicine, Faculty of Medicine and Health Sciences, Atma Jaya Catholic University Jakarta, Indonesia.
Received Date: 18/01/2022; Published Date: 16/02/2022.
*Corresponding author: Yudistira Panji Santosa, Department of Internal Medicine, Faculty of Medicine and Health Sciences, Atma Jaya Catholic University Jakarta, Indonesia
DOI: 10.55920/IJCIMR.2022.01.001034
Abstract
Acute coronary syndrome (ACS) is a common cause of acute chest pain. Ventricular arrhythmias often occur in early ACS and may cause cardiac arrest. Prompt cardiopulmonary resuscitation and defibrillation increase survival in sudden cardiac arrest patients which are caused by ventricular arrythmias. Coronary angiography, followed by percutaneous coronary intervention (PCI) is also associated with improved short- and long-term survival. We present a case series of two male middle-aged patients, active smokers, present with acute chest pain and had cardiac arrest due to Ventricular Tachycardia, both were resuscitated and undergo primary PCI.
Introduction
Acute Coronary Syndromes (ACS) is a common cause of acute chest pain and is a leading cause of in-hospital cardiac arrest. Ventricular tachycardia (VT) or ventricular fibrillation (VF) are considered as STEMI equivalent [1, 2]. Prompt high-quality cardiopulmonary resuscitation (CPR) and early defibrillation is mandatory to increase survival in sudden cardiac arrest patients caused by pulseless ventricular tachycardia (VT) and ventricular fibrillation (VF) [3]. Post cardiac arrest electrocardiogram (ECG) is important to determine the cause of arrest. Urgent coronary angiography with revascularization in post cardiac arrest patients, improves outcome. Coronary artery lesion is found on 96% and 58% in patients with and without ST elevation [1]. This acute angiography followed by percutaneous coronary intervention is associated with improved survival in cardiac arrest patients [2]. We present successful cases of two middle aged men, active smokers, present with acute chest pain and had cardiac arrest due to VT on emergency department, which later were resuscitated and undergo primary PCI.
Case Report
A 58-year-old male, active smoker, presented with six hours chest pain. The chest pain was central and was associated with shortness of breath. There was no history of diabetes, renal disease, dyslipidemia, or hypertension. On admission, the patient was alert, but lethargic. His vital signs: blood pressure 100/60 mmHg, heart rate 70 beats/minute, and respiratory rate 22 breaths/minute. Heart sounds were normal, and no murmurs or additional heart sounds were appreciated. Lung auscultation was vesicular.
Laboratory work on admission showed normal renal function, leukocytosis, and normal blood glucose level. His troponin I level was elevated (387.8 ng/mL, normal < 2 ng/mL). The electrocardiogram showed ST elevations in V1-V4 leads. Electrocardiogram is shown in (Figure 1). During treatment in emergency unit, the patient had acute chest pain with seizure, then he was unconscious and pulseless. His monitor showed tachycardia with wide QRS complexes (heart rate 198 beats/minute). We resuscitated patient with defibrillator, amiodarone injection, adrenalin boluses, and the patient was intubated. After fifty minutes, he was ROSC with hemodynamic blood pressure 74/47 mmHg, heart rate 68 beats/minute (with noradrenalin, dobutamine and dopamine) and respiratory rate 28 breath/minute (with intubation and ventilator). Post CPR electrocardiogram after is shown in (Figure 2).
After initial treatment with loading dose of aspirin and ticagrelor, the patient was transferred to catheter laboratory unit. Angiogram showed one vessel disease. There was total occlusion in proximal left anterior descendent (LAD) artery and was treated by one drug eluting stent. Angiogram and PCI showed in (Figure 3,4 and 5). From secondary survey, his left ventricular ejection fraction was 48% and chest X-ray showed cardiomegaly with pneumonia. Chest x ray showed in (Figure 6). After primary Percutaneous Coronary Intervention (PCI), we treated with inotropic drugs, heparin drip, double antiplatelet, statin and antibiotics for pneumonia. After 24 hours, inotropic drugs tapering off, and heparin instituted until 48 hours. Patient was discharged from after 72 hours hospitalization.
Figure 1: Electrocardiogram when arrived in hospital.
Figure 2: Electrocardiogram post ROSC.
Figure 3: Angiogram, total stenosis Left Anterior Descendent with normal Left Circumflex.
Figure 4: Angiogram Cranial 40, total stenosis Left Anterior Descendent.
Figure 5: Angiogram post PCI, stented 1 DES in Left Anterior Descendent.
Figure 6: Chest x ray showed cardiomegaly and pneumonia.
A 56-year-old Male, arrived in emergency unit with two hours chest pain. The chest pain was central and was associated with shortness of breath. There was no history of diabetes, renal disease, smoking, dyslipidemia, or hypertension. He had history of coronary artery disease history for three years. In Emergency unit, patient had seizure, continued with loss of consciousness and pulseless carotid artery. Monitor revealed ventricular tachycardia. (Figure 7). We resuscitated with defibrillator, amiodarone injection, adrenalin boluses, and he was intubated. After thirty minutes, the patient was ROSC with unstable hemodynamic status: blood pressure 64/45 mmHg, heart rate 108 beats/minute (with noradrenalin, dobutamine and dopamine) and respiratory rate 28 breath/minute (with intubation and ventilator). Electrocardiogram after resuscitation showed in figure 8. There were muffled heart sounds, and no murmurs were appreciated. Auscultation of the lung revealed rales.
Figure 7: Ventricular Tachycardia.
Laboratory work on admission showed normal renal function and leukocytosis. He had slightly elevated troponin I level of 4.2 ng/mL (normal < 2 ng/mL). After initial treatment with loading dose aspirin and ticagrelor, patient was transferred to catheter laboratory unit. Angiogram showed two vessel diseases. There were total occlusion in proximal left anterior descendent (LAD) and total in-stent restenosis in left circumflex (LCx) artery. We treated by one drug eluting stent in LAD. Angiogram was shown in (Figure 9, 10, 11). Secondary survey showed that reduced left ventricular ejection fraction (EF 29%) and chest X-Ray showed cardiomegaly with pulmonary oedema. Chest X-Ray showed in (Figure 12). After primary PCI, he was treated with inotropic drugs, heparin drip, double antiplatelet, statin and diuretic. After 48 hours, inotropic drugs were tappered off, and heparin instituted until 72 hours. Patient dismissed from hospital after seven days in hospitalized. After several months, we treated in stent restenosis in Left Circumflex artery with 2 Drug eluting stents. PCI in LCX shown in (Figure 13).
Figure 8: Electrocardiogram post resuscitate.
Figure 9: Total stenosis di LAD and total In-stent Restenosis in LCx.
Figure 10: Angiogram Cranial 40. Total stenosis di Left Anterior Descendent.
Figure 11: Angiogram post PCI, Stented 1 DES in Left Anterior Descendent.
Figure 12: Chest X ray shown cardiomegaly and pulmonary edema.
Figure 13: Angiogram Post PCI 2 DES in Left Circumflex.
Discussion
Chest pain is one of the most common symptoms presents in emergency departments. Acute coronary syndrome must be quickly recognized by ECG changes and elevated cardiac enzymes [4]. Up to 50% ACS present with cardiac arrest and sudden death as its first manifestation. Ventricular tachyarrhythmias (Vas) are often found in early ischemia, 5% occur within 48 hours after admission, and increase risk of mortality [5, 6]. VA before revascularization is usually related to actively evolving infarct which initiate ventricular arrhythmias [7]. Infarct size is proportionally related with incidence of VA. One third STEMI patients, usually those who have cardiogenic shock, are at increased risk of VA. VA incidence may be reduced by prompt revascularization and drug therapy [8, 9]. Both of our patients present with acute onset of chest pain due to ACS, which were proven by ECG changes and elevated Troponin I.
Rapid, sustained VT may cause cardiac arrest, which may be an initial manifestation of ischaemic heart disease and is considered as STEMI equivalent. This wave is shockable and statistically responds better to resuscitation than pulseless electrical activity (PEA) or asystole [5, 6]. After resuscitation, ECG can be used for differentiating coronary and non-coronary cause of cardiac arrest. Nevertheless, global myocardial ischemia-reperfusion state after cardiac arrest may cause widespread repolarization and conduction abnormalities in post-resuscitation ECG, which affect post-resuscitation ECGs [10]. After ROSC is achieved, patients with or without ST elevation should undergo CT or invasive coronary angiography to confirm any ischemic heart disease, which if present, leads to early myocardial revascularization [5, 6, 11]. Therapeutic hypothermia should also be done in post arrest patients to improve neurological outcome [5, 6].
Several studies showed improved survival in patients undergo coronary angiography, after VT/VF cardiac arrest [12, 13]. Left anterior descending (LAD) coronary artery is commonly found in VT/VF [7]. Currently, acute coronary atherothrombosis may only be detected by coronary angiography and subsequent PCI can be done to restore coronary blood flow and prevent reoccurrence of life-threatening arrhythmias [10]. Our patients were resuscitated with defibrillation, high quality CPR, amiodarone, and epinephrine. They were intubated during resuscitation. Post-arrest ECG were obtained and II, III, aVF, V1-V4 leads had ST segment elevation on both patients. They both had coronary angiography and obstruction of LAD was found on both patients, and circumflex artery was obstructed on second patient. PCI was immediately done in both patients, and their condition were getting better after treatment.
Echocardiography is also recommended in patients with known or suspected VA, to evaluate any abnormality of cardiac structure and function. If available, cardiac CT or MRI may be sufficient tools for evaluation. Patients with VT/VF have lower left ventricle ejection fraction (LVEF) [7]. In our patients, both had reduced EF (lower on second patient). The patients were also treated with dual antiplatelet and heparinization as recommended by the guideline. Outcome in our patients were good, as studies have shown immediate PCI reduced short-term (day-30) and long-term mortality [14].
Conclusion
Acute Coronary Syndromes (ACS) is a common cause of acute chest pain and is a leading cause of in-hospital cardiac arrest, can be detected quickly by recognizing ECG changes and elevation of cardiac enzymes. Cardiac arrest due to ventricular tachyarrhythmias are often found in early ischemia and associated with increased risk of mortality if not well managed. Emergent coronary angiography is recommended in ROSC patient, helps identify acute thrombosis and immediate PCI can be done simultaneously, which increase short- and long-term survival.
Reference
- Reddy S, Lee KS. Role of Cardiac Catheterization Lab Post Resuscitation in Patients with ST Elevation Myocardial Infarction. Currunte Cardiol Rev. 2018; 14:85-91. [DOI:10/2174/1573403X14666180517080828].
- Luscher TF. Acute coronary syndromes and sudden cardiac death in the modern era. Eur Heart J. 2017; 38:1617-1620. [DOI:10.1093/eurheartj/ehx262].
- Panchal AR, Bartos JA, Cabanas JG, et al. Part 3 : Adult Basic and Advanced Life Support. 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020;142(Suppl 2):S366-S468. doi:10.1161/CIR.0000000000000916
- DeVon HA, Mirzaei S, Zègre-Hemsey J. Typical and Atypical Symptoms of Acute Coronary Syndrome: Time to Retire the Terms? J Am Hear Assoc. 2020; 9:e015539. [DOI:10.1161/JAHA.119.015539].
- Gorecka M, Hanley A, Burke F, Nolan P, Crowley J. Cardiac arrest secondary to acute coronary syndrome: a 4-year observational study of patient characteristics and outcomes. Ir J Med Sci. 2017; 186(1):129-132. [DOI:10.1007/s11845-016-1422-x].
- Al-Khatib SM, Stevenson WG, Ackerman MJ, et al. 2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death. 2018; 138. [DOI:10.1161/CIR.0000000000000549].
- Kosmidou I, Embacher M, McAndrew T, et al. Early Ventricular Tachycardia or Fibrillation in Patients With ST Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention and Impact on Mortality and Stent Thrombosis (from the Harmonizing Outcomes with Revascularization and . Am J Cardiol. 2017; 120(10):1755-1760. [DOI:10.1016/j.amjcard.2017.07.080].
- Bhar-Amato J, Davies W, Agarwal S. Ventricular arrhythmia after acute myocardial infarction: ‘The perfect storm’. Arrhythmia Electrophysiol Rev. 2017; 6(3):134-139. [DOI:10.15420/aer.2017.24.1].
- Andersen JA, Freeman P, Larsen JM, Andersen NH. Monomorphic ventricular tachycardia as the primary presentation of an anterior STEMI. Clin Case Reports. 2019; 7(9):1680-1684. [DOI:10.1002/ccr3.2324].
- Spoormans EM, Lemkes JS, Janssens GN, van der Hoeven NW, Bonnes JL, van Royen N. The role of coronary angiography in out-of-hospital cardiac arrest patients in the absence of ST-segment elevation: A literature review. Netherlands Hear J. 2020; 28:108-114. [DOI:10.1007/s12471-020-01460-8].
- Zanuttini D, Armellini I, Nucifora G, et al. Predictive value of electrocardiogram in diagnosing acute coronary artery lesions among patients with out-of-hospital-cardiac-arrest. Resuscitation. 2013; 84(9):1250-1254. [DOI:10.1016/j.resuscitation.2013.04.023].
- Patel N, Patel NJ, Macon CJ, et al. Trends and Outcomes of Coronary Angiography and Percutaneous Coronary Intervention After Out-of-Hospital Cardiac Arrest Associated With Ventricular Fibrillation or Pulseless Ventricular Tachycardia. JAMA Cardiol. 2016; 1(8):890-899. [DOI:10.1001/jamacardio.2016.2860].
- Vyas A, Chan PS, Cram P, Nallamothu BK, McNally B, Girotra S. Early Coronary Angiography and Survival After Out-of-Hospital Cardiac Arrest. Circ Cardiovasc Interv. 2016; 8(10). [DOI:10.1161/CIRCINTERVENTIONS.114.002321].
- Geri G, Dumas F, Bougouin W, et al. Immediate Percutaneous Coronary Intervention Is Associated with Improved Short-and Long-Term Survival after Out-of-Hospital Cardiac Arrest. Circ Cardiovasc Interv. 2015; 8(10):1-7. [DOI:10.1161/CIRCINTERVENTIONS.114.002303].
