FIGURE 60-1 Ambulatory ECG while patient was at the hospital cardiac rehabilitation unit for therapy shows the sudden onset of ventricular fibrillation.

FIGURE 60-2 Ambulatory ECG shows successful external cardioversion to a slower and more stable rhythm.

EXPERT OPINION

• Patients who have had a recent MI are at high risk for sudden cardiac death, particularly if their EF is low.¹

• The potential cardiac causes of sudden death following MI include:

Recurrent ischemia

Cardiac rupture

Tachyarrhymias (ie, ventricular tachycardia [VT] and VF)

Bradyarrhythmias (ie, complete heart block)

• Tachyarrhymias and bradyarrhythmias could be secondary to recurrent ischemia.

• Typically, VF or polymorphic VT is due to recurrent ischemia or cardiac rupture while monomorphic VT is due to a reentrant circuit from the MI scar.

• In the absence of evidence for cardiac rupture, the management of post-MI patients with syncope or life-threatening arrhythmias typically begins with ruling out recurrent ischemia, especially when the presenting rhythm is VF or polymorphic VT.

PATHOPHYSIOLOGY AND MANAGEMENT

• The patient had two more episodes of VF requiring external cardioversion in the CCU.

• Troponin was found to be positive.

• Emergent cardiac catheterization found a stenosis at the anastomosis of the LIMA to the LAD, which was opened by PTCA. The vessel was considered too small and tortuous for stent delivery.

• Echo following VF arrest showed an EF of 30% and no thrombus.

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