Mon25October0844PM 10

A 62-year-old man is admitted to the Emergency department with an episode of ventricular tachycardia. He collapsed in the local supermarket. The VT was captured on the ambulance recording strip, and he reverted spontaneously.

He was discharged from the coronary care unit after suffering an extensive anterior MI (for which he received two stents), some two weeks earlier. He has been prescribed multiple medications including ramipril 10 mg, furosemide 40 mg and bisoprolol 5 mg.

Examination reveals a BP of 105/80 mmHg, pulse is 84 and regular. There are bilateral basal crackles consistent with heart failure, and bilateral pitting oedema of both ankles.

Investigations reveal:

Hb 134 g/L (135-180)

WCC 7.0 ×109/L (4.5-10)

PLT 200 ×109/L (150-450)

Na 140 mmol/L (135-145)

K 5.2 mmol/L (3.5-5.5)

Cr 132 µmol/L (70-110)

ECG shows deep anterior Q waves, 1-2 mm of ST elevation in V2-V5.

CXR shows LVH.

ECHO shows evidence of possible LV aneurysm, ejection fraction 22%.

Which of the following is most appropriate intervention with respect to the VT?

(Please select 1 option)

Surgical excision of aneurysm

Implantable cardioverter defibrillator Correct

Outpatient Holter monitor

Increased dose of bisoprolol

Oral amiodarone

Explanation

Given this patient's ejection fraction, and possible LV aneurysm, his prognosis with respect to further episodes of VT and sudden cardiac death is very poor. As such progression to implantable cardioverter defibrillator (ICD) insertion at an early stage is recommended.

Increased dose of bisoprolol will not significantly reduce the likelihood of further episodes of VT in this situation in light of the underlying LV aneurysm and very poor ejection fraction.

In studies oral amiodarone has proven inferior to ICD implantation with respect to survival and as such is not the preferred option here.

Arranging an outpatient Holter monitor risks a potentially fatal VT episode whilst the investigation is being arranged.

Aneurysm excision is reserved for those with recurrent VT despite other interventions.

The patient should of course be assessed for the presence of intraventricular thrombus, as anticoagulation may be required.

Answer Statistics

1

10%

2

80%

3

2%

4

5%

5

6%

Times answered: 270