Cardiology Case Presentation

MS-III
CC
• Unexplained cardiac arrest
HPI
65-year-old white female pt presents to the office for cardiology evaluation after experiencing an unexplained
cardiac arrest 2 weeks ago while she was undergoing LT hip arthroplasty in an outpatient setting. Per ortho
records, the surgery was in its final stages when ventricular tachycardia was suddenly noted on the monitor.
The surgery was aborted, CPR was administered, and the rhythm returned to normal within a few seconds.
Cardiac catheterization was then performed that showed no evidence of coronary arterial disease; however, an
anomalous RCA origin was noted. A subsequent echocardiogram showed reduced ejection fraction of 40-45%.
Hospital labs were unremarkable except for Hb 6.1 which was treated with blood transfusion; however, the Hb
increased to 15.4 after transfusion, which suggested the detected anemia was a result of a blood draw error
due to proximity to IV fluids. The patient was ultimately cleared for completion of hip surgery and was
discharged home shortly afterwards.
Today the patient reports generalized weakness and dizziness described as lightheadedness, shortness of
breath, and 17 lbs of weight loss. She attributes the weight loss to a decrease in activity over the last couple
weeks but also states she had COVID-19 three months ago and still has not regained her sense of taste. This
makes her nauseous and food-averse, and she has not had as many bowel movements as usual (now every 2-3
days compared to 1-2 daily) particularly since being home from the hospital. She also feels like she has had
“mental fog” since the COVID infection but states this has mildly improved. She reports feeling weak when she
gets out of bed in the morning and short of breath with minimal exertion, such as walking 100-200 yards in the
parking lot. Her comfort with activity is also limited by continued aching of her LT hip s/p surgery and her RT
knee attributed to her chronic arthritis. No syncopal episodes, chest pain, diaphoresis, or vomiting.
• PMH: hypertension, hyperlipidemia, osteoarthritis b/l knees and hips, worse in LT hip and RT knee
• PSH: LT hip arthroplasty 03/2021, subtotal hysterectomy 06/2007, tonsillectomy “when I was a
teenager”
• SH: Retired real estate agent, never smoked or used other tobacco products, drinks 3-4 glasses of
wine per week with dinner, reports occasional PO marijuana recreationally, prior to COVID
infection exercised daily and ran 20-30 miles per week, since COVID infection has decreased to
10-15 miles per week and since discharge from hospital is not exercising at all
• FH: Mother: Hypertension and lung cancer, deceased @ 79 y/o
Father: Hypertension, hyperlipidemia and Parkinson’s, deceased @ 87 y/o
Brother: Colorectal cancer, living, 69 y/o

• Meds: lisinopril 20 mg PO daily, ASA 81 mg PO daily, atorvastatin 40 mg PO at bedtime, digoxin

0.25 mg PO daily, oxycodone HCL 5 mg 1 PO every 6 hours or as needed, Docusate 100 mg PO
twice daily or as needed, Zofran 1 PO twice daily or as needed, Tylenol PM Extra Strength as
needed, women’s multivitamin
• Allergies: Sulfa-shortness of breath, adhesive bandages-rash, hay fever
ROS
General: positive for weight loss & generalized weakness, negative for fever or chills
Eyes: negative for vision loss, floaters, or yellow tint
HEENT: positive for loss of taste and smell, negative for sore throat, tinnitus, or neck pain
Cardiovascular: positive for dizziness, lightheadedness & DOE, negative for CP, syncope or near-syncope,
intermittent claudication, palpitations, PND, orthopnea, or swelling of hands or feet
Respiratory: negative for excessive snoring
Genitourinary: negative for incontinence or hematuria
Gastrointestinal: positive for nausea and constipation, negative for vomiting
MSK/Extremities: positive for b/l hip and knee pain, L>R hip, R>L knee, negative for skin changes
Skin: negative for erythema, purulence, contusions, or lacerations
Neurological: positive for “mental fog,” negative for headache
Psychiatric: negative for depression or anxiety
Endocrine: negative for excessive thirst or urination
Heme/Lymphatic: negative for enlarged lymph nodes or abnormal bruising
VS
• HT: 67”
• WT: 157 lbs
• BMI: 24.59
• O2 Sat: 98% on RA
• HR: 68 bpm
• BP: 130/82 (seated, LT arm)
Physical Exam
General: well-developed, well-nourished, NAD
HEENT: normocephalic, moist oral mucosa, PERRLA, EOMI, no conjunctival pallor or
scleral icterus
Neck: no JVD, carotid bruit, or thyromegaly
Cardiovascular: RRR, no MRG, no S3 or S4
Respiratory: no chest deformities, lungs CTA and percussion
Abdominal: soft, nontender, no masses, bruits or HSM
MSK/Extremities: peripheral pulses 2+ bilaterally, no clubbing, cyanosis or edema
Skin: no rashes, surgical site without evidence of infection or poor healing
Neurological: A&Ox4, no FND
Psychiatric: appropriate and cooperative
EKG
HR 64 BPM
NSR
PR slightly prolonged
QRS normal width
QT normal
No STE
Inverted T-waves in I, aVL, V2
Peaked T-waves in III

Interpretation: NSR, first-degree

heart block, some evidence
of prior ischemia, inconclusive

Did appear changed from previous

EKG from ortho pre-op clearance
which showed NSR and some
nonspecific T-wave changes
Assessment & Plan
1. Ventricular tachycardia leading to cardiac arrest, single known event, idiopathic, stable
No further cardiac arrests since the isolated episode on the operating table in March. Not observed in office. Continue baby
aspirin and other post-cardiac arrest medications as noted elsewhere. Repeat EKG on follow-up visit. Call 9-1-1 in the event of
syncope, chest pain, or any other concerning symptoms. Call office if experience palpitations.
2. Dilated cardiomyopathy, idiopathic
Potentially a result of chronic hypertension, resuscitation and hospitalization, COVID infection, or underreported alcohol use.
EF of 40-45% is mildly decreased, and previous EF is unknown given this patient’s relative lack of previous cardiovascular
workup. CAD was ruled out with coronary angiography. D/c digoxin due to narrow therapeutic window, unfavorable side effect
profile, potential for arrhythmogenicity, and prolonged PR interval today suggesting possible AV block. Start metoprolol
succinate 25 mg at night. Patient educated about purpose of medication, importance of adherence, and side effects. Repeat
echocardiography in 6 months to reassess ejection fraction. Follow up 2 weeks after testing to review findings.
3. Hypertension, chronic, stable
Continue lisinopril 10 mg daily. Should see additional antihypertensive effect from added beta-blocker. Measure blood
pressure at next visit, goal < 130/80. Recommended low-sodium diet and activity as tolerated.
4. Hyperlipidemia
Continue atorvastatin 40 mg daily and avoid excessive dietary cholesterol. Monitor blood lipids per PCP.
5. Post-COVID syndrome
Monitor neurological symptoms. Management per PCP.
Discussion
• Intraoperative cardiac arrest is uncommon, occurring in ~1 to 5/10,000 surgeries.
• There are numerous potential causes, many of which are contained in the ACLS Hs and Ts.
• The cause may be related to known patient comorbidities such as heart failure,
intraoperative measures, or remain idiopathic.
• It is not always clear whether the related condition, like this patient’s cardiomyopathy,
preceded or followed the cardiac arrest event. However, dilated cardiomyopathy is one of
the most common causes of ventricular tachycardia and related sudden cardiac death.
Other forms of structural heart disease such as CAD and hypertrophic cardiomyopathy may
also be implicated. There may be a pathway by which abnormal stretching or strain on the
myocardium irritates arrhythmogenic foci that escape overdrive suppression.
• Initial management involves determination of whether the rhythm is shockable or not; in
this case, the patient was in pulseless V-tach, which calls for cycles of CPR, epinephrine,
and defibrillation.
• This patient’s rapid return to NSR was fortunate, as only ~33% of patients experiencing
intraoperative cardiac arrest survive to hospital discharge.
• Once this patient became stable, she was taken to the cath lab in attempts to identify any
coronary artery blockages that could have caused a ventricular arrythmia. Stat labs were
also drawn in attempts to identify Hs and Ts that could be corrected during her hospital
stay. In her case, no obvious contributors were found save for anemia, which was
attributed to poor blood draw technique.
Discussion
• Dilated cardiomyopathy is characterized by eccentric hypertrophy of the myocardial wall,
leading to enlarged intraventricular chamber(s) and potentially overt heart failure.
• It is diagnosed when echocardiography demonstrates dilation and EF <40%.
• It can affect patients of any age, although middle age is the most common demographic.
Similar to this patient, symptoms of heart failure (DOE, orthopnea, neck vein or extremity
swelling, etc.) predominate.
• Idiopathic causes are the most common. In order from most to least common, other
causes include: other unspecified causes, myocarditis, ischemic heart disease, infiltrative
disease, peripartum cardiomyopathy, hypertension, HIV, connective tissue disease,
substance abuse, and Doxorubicin. In the case of this patient, her normal cardiac
catheterization ruled out CAD, despite her risk factors of hypertension, hyperlipidemia,
and postmenopausal status (estrogen is cardioprotective).
• Generally speaking, the treatment depends on the cause.
• Patients like the one discussed here may be treated with beta-blockers to decrease the
stress placed on the heart by decreasing blood pressure and myocardial oxygen demand.
The physician I shadowed explained that 6 months of treatment may give the patient’s
heart time to recover from injury, and it is possible her EF will subsequently increase.
• Patients with dilated cardiomyopathy may ultimately require heart transplants as their
heart failure worsens and they cease to be able to produce life-sustaining stroke volumes.
In addition, fatal arrythmia is a common cause of death in these patients.
Discussion
• COVID-19 infection is emerging as a possible cause of serious cardiovascular complications.
• It may be difficult to separate risk factors from results of COVID-19 infection, as obesity,
diabetes, etc. are linked to worse COVID-19 outcomes as well as cardiovascular disease.
• However, several interesting findings have developed from the study of hospitalized COVID
patients, including elevated troponins and BNPs on admission.
• Physiologic stress appears to play a role in numerous cases, like stress myocarditis, ARDS
and/or pulmonary embolism-associated cor pulmonale, and multisystem inflammatory
syndrome.
• COVID-19 has also been linked to new-onset arrythmias.
• COVID-19 cannot be ruled out as a potential contributor to this patient’s mysterious
intraoperative arrythmia and/or dilated cardiomyopathy, given the absence of a single
clear cause and the establishment of this patient’s recent COVID-19 infection. She has also
remained symptomatic neurologically, and it is not unreasonable to conclude this nascent
condition may have significant long-term effects on various organ systems long after the
initial period of infection.
• This is a fascinating field of study and one that will continue to develop as patients may be
followed for longer periods of time and the pathophysiology of COVID-19 becomes better
understood.
References
• Ben-Jacob TK, Moitra VK, O’Connor MF. Perioperative advanced cardiac life
support (ACLS). In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA.
(Accessed on April 09, 2021.)
• Caforio, ALP. COVID-19: Cardiac manifestations in adults. In: UpToDate, Post
TW (Ed), UpToDate, Waltham, MA. (Accessed on April 11, 2021.)
• Callans, VJ. Ventricular tachycardia in the absence of apparent structural
heart disease. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA.
(Accessed on April 09, 2021.)
• Weigner M, Morgan JP. Causes of dilated cardiomyopathy. In: UpToDate,
Post TW (Ed), UpToDate, Waltham, MA. (Accessed on April 10, 2021.)
• Wilson, PWF. Overview of established risk factors for cardiovascular
disease. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed
on April 10, 2021.)