A 83 yrs old gentleman, known Type 2 Diabetes Mellitus, Systemic Hypertension, Benign Prostatic Hyperplasia and Hypothyroid on regular medications came to the Emergency Department with H/O Vacant Stares at home. He suffered a total of three episodes on the same day he was brought to the hospital. Each event lasted for a few minutes. The patient was standing during all the events and was not fully aware of what was happening around him during the event. H/O mild blurring of vision during the event. No H/O fall occurred during the event, and there were no similar events in the past. There were no H/O Tonic clinic movements, no involuntary voiding of urine/bowels, and no H/O fever. The patient is currently on T. Trivolib, T. Inoglam, T. Amlopres L, T. Eltroxin, T. Urimax D, and T. Roseday
Upon arrival at the Emergency Department, he was fully conscious, oriented, afebrile. The initial vitals were: HR- 120/min, BP- 130 / 70mmHg, RR- 24/min, SpO2-96%, Temp- 98 F, CBG- 264 mg/dl, GCS- E4V5M6. He was Triaged and received in a Triage 1 Bed. He was connected to the monitor was when he had another event of Vacant Stares. Monitor showed:
Theill-sustained monomorphic Ventricular Tachycardia lasted for about 10 seconds. There were multiple events of monomorphic ventricular tachycardia occurring at regular intervals.
An IV Access was placed and a Cardiologist was put in the loop. Initial blood tests and an ECG showed ill-sustained monomorphic ventricular tachycardia.
The Provisional diagnosis was of Cardiac Syncope, Monomorphic Ventricular tachycardia, possibly due to Dyselectrolytemia / ACS He was initially managed with IV Cardarone and IV magnesium sulphate. A loading dose was given and heparinised. After 30 min of initial resuscitation, the monitor showed:
An ECG that was taken later showed normal sinus rhythm with q waves in inferior leads:
The patient was shifted to the CCU for cardiac monitoring. He was planned for CAG which shows calcified triple vessel disease of LAD, OM1, Distal LCX, RCA,PDA and was planned for multivessel PCI. CABG was deferred because of his advanced age.
A High Risk Multivessel PCI using shockwaves and stenting was done for LCX to OM and Proximal LAD with drug eluding Balloon angioplasty to RCA and PDA. The Post-op situation was uneventful. The patient recovered well. He was discharged with medications and is on regular follow-up.
Usually, multivessel PCI is deferred in patients with severe calcified triple vessel disease. But in his case, it was possible using shock wave lithotripsy.
Points to take home: 1 . Monomorphic ventricular tachycardia is most commonly ischemia/injury induced. 2 . It is the most common cause of sudden death in a previously normal individual. 3 . Even minor cardiac symptoms should not be ignored as they can cost people their lives. 4 . Angioplasty can be an effective alternative for high-risk surgical subjects, like elderly persons > 80yrs of age 5 . Drugs used to treat arrhythmia can also induce arrhythmia. Eg: cardarone can cause qt prolongation which can result in arrhythmias. 6 . Beta-blockers are the drug of choice to treat Ventricular Tachycardia in the context of Acute Coronary Syndrome
Dr. Karunakaran Vetri, Emergency Specialist / Emergency Physician
