unique presentation of a heart failure patient - LifeVest

UNIQUE PRESENTATION OF A
HEART FAILURE PATIENT
Norman Marcus, MD
The Heart Care Group, Allentown, PA
ZOLL • Pittsburgh, PA
20C0093 rev_FI
Patient ID: De-identified
Patient Name: De-identified
Event Date Time: De-identified 2009 12:14 AM
Patient ID: De-identified
Patient Name: De-identified
Event Date Time: De-identified 2009 12:14 AM
SS Channel: Amplitude Scale = 1 mv/10 mm
5
4 Amplitude Scale = 1 mv/10 mm
SS Channel:
5
4
Recording Speed - 25 mm/Second
3 Recording Speed - 25 mm/Second
3
2
3
2
3
UNIQUE PRESENTATION OF A HEART FAILURE PATIENT
UNIQUE PRESENTATION OF A HEART FAILURE PATIENT
By Norman Marcus, MD
By Norman Marcus, MD
HISTORY OF PRESENT ILLNESS (HPI) A 58 year old male presented to an Emergency Center after
experiencing increasing dyspnea, fatigue, and chest pain during the previous week. The patient had a history
of congestive heart failure (CHF) but was not on any relevant medications. He had a history of colon cancer
which was successfully treated with radiation and a potentially cardiotoxic chemotherapy drug five years
previous to this emergency.
delivered a 150J biphasic treatment shock 41 seconds after detection. The treatment successfully converted his
arrhythmia33to a NSR at
a rate of 77
BPM. The
patient woke
his wife,
who was 39sleeping in 40another room, to
34
35
36
37
38
call 911. He
met
the
ambulance
outside
his
house,
and
he
was
taken
for evaluation.
33
34
35
36
37
38 to the hospital
39
40
FB Channel: Amplitude Scale = 1 mv/10 mm
4
FB Channel: Amplitude Scale = 1 mv/10 mm
4
Recording Speed - 25 mm/Second
Recording Speed - 25 mm/Second
PHYSICAL EXAMINATION The patient was experiencing acute chest pain. His EKG showed atrial flutter with
2:1 conduction resulting in a ventricular rate of 150 beats per minute (BPM) and a left bundle branch block
(LBBB). His blood work was remarkable for an elevated troponin level of 14.56. He also displayed clinical
symptoms of CHF.
33
He was transported to a tertiary care facility by helicopter for emergent cardiac catheterization.
34
33
34
SS Channel: Amplitude Scale = 1 mv/10 mm
3
SS Channel:4Amplitude Scale = 1 mv/10 mm
STUDIES/RESULTS Cardiac catheterization was performed and revealed no significant occlusions or evidence
of coronary artery disease (CAD). His left ventricular ejection fraction (LVEF) was determined to be 20%.
During the study, his EKG displayed normal sinus rhythm (NSR).
3
4
35
36
35
36
Recording Speed - 25 mm/Second
5
Recording
Speed - 25 mm/Second
5
37
38
39
40
37
38
39
40
47
48
6
7
6
7
The patient was hospitalized and medically treated for his heart failure symptoms. On telemetry, he had one run
of nonsustained, wide complex tachycardia, with evidence of A-V dissociation suggesting a ventricular origin.
41
IMPRESSIONS/PLAN Electrophysiology was consulted due to the initial presentation of atrial flutter and
the nonsustained tachycardia. It was determined that the atrial arrhythmia likely contributed to the patient’s
worsening CHF symptoms.
42
43
44
45
46
Figure 1: EKG downloaded from WCD. The WCD continuously monitors the patient’s EKG using a 4 electrode, 2 lead
41
42
43
44
45
46
47
48
FB Channel:
Amplitude Scale =(FB,
1 mv/10
mmand side-to-side
Recording Speed
- 25 bottom)
mm/Second
system
-front-to-back
top)
(SS,
4
FB Channel: Amplitude Scale = 1 mv/10 mm
5
Recording
Speed - 25 mm/Second
6
7
The patient received a cardiac resynchronization device (CRT-D) implant the following day. During device
testing, the patient initially failed defibrillation threshold testing and subsequently had a subcutaneous
(SQ) array implanted. The implantation of the SQ array successfully provided an adequate defibrillation
safety threshold.
4
The patient underwent a successful atrial flutter ablation. During the procedure, he was not inducible for a
ventricular arrhythmia in the EP lab.
The goal was to optimize his medical therapy to reduce the patient’s heart failure symptoms and his medical
regimen included: Losartan, spironolactone, furosemide, carvedilol, esomeprazole, ASA, amlodipine,
and warfarin.
5
6
7
The patient returned home and has since returned to his full time employment as a state corrections officer.
He has not required defibrillation therapy from his device.
The patient was discharged home on day six. In addition to medications, the patient was prescribed a wearable
cardioverter defibrillator (WCD), (manufactured by ZOLL, Pittsburgh, PA, marketed under the brand
name LifeVest®).
41
42
43
44
45
46
47
48
41
42
43
44
45
46
47
48
DISCUSSION Treating the heart failure patient can be made more difficult due to unique presentations of
symptoms. In this case study, the patient was initially flown to the cardiac catheterization laboratory due to
test results and symptoms. No evidence of CAD was discovered. Despite a successful atrial flutter ablation
procedure and three months of optimizing medical therapy, the patient’s EF did not improve significantly.
During the medical therapy optimization period, the patient was at risk for SCA and was protected with a
WCD. The patient is now on optimized medical therapy and has been implanted with a CRT-D device. He
has returned to work without further heart failure or SCA episodes.
He was scheduled to have his ejection fraction reevaluated in three months. If at that time his LVEF remained
≤35%, an ICD would be considered for permanent SCA protection.
CLINICAL UPDATE The patient’s LVEF was reevaluated and, despite optimal medical management, it was
determined that his EF had not improved. He was scheduled to be implanted with a cardiac resynchronization
device (CRT-D).
The evening before implantation surgery the patient lost consciousness at home while working on his
computer. The WCD appropriately detected a polymorphic VT at a rate of 298 BPM (see Figure 1), and
PAGE 1
Written by Dr. Norman Marcus with support from ZOLL.
PAGE 2
Patient ID: De-identified
Patient Name: De-identified
Event Date Time: De-identified 2009 12:14 AM
Patient ID: De-identified
Patient Name: De-identified
Event Date Time: De-identified 2009 12:14 AM
SS Channel: Amplitude Scale = 1 mv/10 mm
5
4 Amplitude Scale = 1 mv/10 mm
SS Channel:
5
4
Recording Speed - 25 mm/Second
3 Recording Speed - 25 mm/Second
3
2
3
2
3
UNIQUE PRESENTATION OF A HEART FAILURE PATIENT
UNIQUE PRESENTATION OF A HEART FAILURE PATIENT
By Norman Marcus, MD
By Norman Marcus, MD
HISTORY OF PRESENT ILLNESS (HPI) A 58 year old male presented to an Emergency Center after
experiencing increasing dyspnea, fatigue, and chest pain during the previous week. The patient had a history
of congestive heart failure (CHF) but was not on any relevant medications. He had a history of colon cancer
which was successfully treated with radiation and a potentially cardiotoxic chemotherapy drug five years
previous to this emergency.
delivered a 150J biphasic treatment shock 41 seconds after detection. The treatment successfully converted his
arrhythmia33to a NSR at
a rate of 77
BPM. The
patient woke
his wife,
who was 39sleeping in 40another room, to
34
35
36
37
38
call 911. He
met
the
ambulance
outside
his
house,
and
he
was
taken
for evaluation.
33
34
35
36
37
38 to the hospital
39
40
FB Channel: Amplitude Scale = 1 mv/10 mm
4
FB Channel: Amplitude Scale = 1 mv/10 mm
4
Recording Speed - 25 mm/Second
Recording Speed - 25 mm/Second
PHYSICAL EXAMINATION The patient was experiencing acute chest pain. His EKG showed atrial flutter with
2:1 conduction resulting in a ventricular rate of 150 beats per minute (BPM) and a left bundle branch block
(LBBB). His blood work was remarkable for an elevated troponin level of 14.56. He also displayed clinical
symptoms of CHF.
33
He was transported to a tertiary care facility by helicopter for emergent cardiac catheterization.
34
33
34
SS Channel: Amplitude Scale = 1 mv/10 mm
3
SS Channel:4Amplitude Scale = 1 mv/10 mm
STUDIES/RESULTS Cardiac catheterization was performed and revealed no significant occlusions or evidence
of coronary artery disease (CAD). His left ventricular ejection fraction (LVEF) was determined to be 20%.
During the study, his EKG displayed normal sinus rhythm (NSR).
3
4
35
36
35
36
Recording Speed - 25 mm/Second
5
Recording
Speed - 25 mm/Second
5
37
38
39
40
37
38
39
40
47
48
6
7
6
7
The patient was hospitalized and medically treated for his heart failure symptoms. On telemetry, he had one run
of nonsustained, wide complex tachycardia, with evidence of A-V dissociation suggesting a ventricular origin.
41
IMPRESSIONS/PLAN Electrophysiology was consulted due to the initial presentation of atrial flutter and
the nonsustained tachycardia. It was determined that the atrial arrhythmia likely contributed to the patient’s
worsening CHF symptoms.
42
43
44
45
46
Figure 1: EKG downloaded from WCD. The WCD continuously monitors the patient’s EKG using a 4 electrode, 2 lead
41
42
43
44
45
46
47
48
FB Channel:
Amplitude Scale =(FB,
1 mv/10
mmand side-to-side
Recording Speed
- 25 bottom)
mm/Second
system
-front-to-back
top)
(SS,
4
FB Channel: Amplitude Scale = 1 mv/10 mm
5
Recording
Speed - 25 mm/Second
6
7
The patient received a cardiac resynchronization device (CRT-D) implant the following day. During device
testing, the patient initially failed defibrillation threshold testing and subsequently had a subcutaneous
(SQ) array implanted. The implantation of the SQ array successfully provided an adequate defibrillation
safety threshold.
4
The patient underwent a successful atrial flutter ablation. During the procedure, he was not inducible for a
ventricular arrhythmia in the EP lab.
The goal was to optimize his medical therapy to reduce the patient’s heart failure symptoms and his medical
regimen included: Losartan, spironolactone, furosemide, carvedilol, esomeprazole, ASA, amlodipine,
and warfarin.
5
6
7
The patient returned home and has since returned to his full time employment as a state corrections officer.
He has not required defibrillation therapy from his device.
The patient was discharged home on day six. In addition to medications, the patient was prescribed a wearable
cardioverter defibrillator (WCD), (manufactured by ZOLL, Pittsburgh, PA, marketed under the brand
name LifeVest®).
41
42
43
44
45
46
47
48
41
42
43
44
45
46
47
48
DISCUSSION Treating the heart failure patient can be made more difficult due to unique presentations of
symptoms. In this case study, the patient was initially flown to the cardiac catheterization laboratory due to
test results and symptoms. No evidence of CAD was discovered. Despite a successful atrial flutter ablation
procedure and three months of optimizing medical therapy, the patient’s EF did not improve significantly.
During the medical therapy optimization period, the patient was at risk for SCA and was protected with a
WCD. The patient is now on optimized medical therapy and has been implanted with a CRT-D device. He
has returned to work without further heart failure or SCA episodes.
He was scheduled to have his ejection fraction reevaluated in three months. If at that time his LVEF remained
≤35%, an ICD would be considered for permanent SCA protection.
CLINICAL UPDATE The patient’s LVEF was reevaluated and, despite optimal medical management, it was
determined that his EF had not improved. He was scheduled to be implanted with a cardiac resynchronization
device (CRT-D).
The evening before implantation surgery the patient lost consciousness at home while working on his
computer. The WCD appropriately detected a polymorphic VT at a rate of 298 BPM (see Figure 1), and
PAGE 1
Written by Dr. Norman Marcus with support from ZOLL.
PAGE 2
UNIQUE PRESENTATION OF A
HEART FAILURE PATIENT
Norman Marcus, MD
The Heart Care Group, Allentown, PA
ZOLL • Pittsburgh, PA
20C0093 rev_FI

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