Cairo University – Faculty of Medicine

Cardiology Department

Examination of the MD Degree in Cardiology

May,  2001. Paper III.

- A 60 years-old man suffered acute inferior wall myocardial infarction two years ago. This was complicated by moderately sever mitral regurgitation. Eight months late he had two episodes of loss of consciousness. On presentation to the emergency department, the ECG revealed a wide QRS tachycardia at 210 bpm that did not respond to administration of lidocaine or procainamide. He was successfully cardioverted to sinus rhythm. Subsequent ECG revealed no recent changes, serum troponin I was 0.2 ng/ml, total CK 70 U/L and CK MB 3 U/L. An echocardiogram showed no change in left ventricular function and no evidence of thrombus. He underwent an electrophysiological study that revealed inducible monomorphic ventricular tachycardia that matched his spontaneous episode. He then underwent implantation of an implantable cardiovertor-defibrillator (ICD) that was capable of ventricular tachycardia or ventricular fibrillation. He was discharged two days later and remained event-free for one month, then began to get recurrent palpitation. His ICD shocked him four times one day and twice the next but he never lost consciousness, the patient was hospitalized for ICD adjustment which was successful in keeping him event-free for one year. While being driven for several hours to a summer resort, he suffered an episode of chest pain and shortness of breath. Shortly thereafter, he received five shocks in rapid sequence. An ambulance was called and on the way to the hospital two more shocks occurred. In the emergency room, he had an average blood pressure of 00/60 mmHg, irregular pulse, jugular venous pressure of 9 cm above the sternal angle and S3 gallop at the lower left sternal border. The ECG revealed atrial fibrillation with a fast ventricular response and a non-specific ST-T changes in V1-V3 serum cardiac markers revealed total CG 60 U/L, CK MB 2 U/L, LDH 375 U/L and troponin 10.3 ng/ml.

- Discuss the above findings and suggest the various treatment options of this patient.