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Sudden cardiac death preceded by ST segment elevations during ECG patch monitoring
Sudden Cardiac Death Preceded by ST Segment Elevations During ECG Patch Monitoring Timothy F. Simpson MD, Pharm.D, Nora Goldschlager MD PII: DOI: Reference:
S0022-0736(17)30419-3 doi: 10.1016/j.jelectrocard.2017.10.010 YJELC 52525
To appear in:
Journal of Electrocardiology
Please cite this article as: Simpson Timothy F., Goldschlager Nora, Sudden Cardiac Death Preceded by ST Segment Elevations During ECG Patch Monitoring, Journal of Electrocardiology (2017), doi: 10.1016/j.jelectrocard.2017.10.010
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Sudden Cardiac Death Preceded by ST Segment Elevations During ECG Patch Monitoring
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Timothy F Simpson, MD, Pharm.Da*, Nora Goldschlager MDb A.Department of Medicine, University of California San Francisco, San Francisco, California.
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B. Division of Cardiology, Department of Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California.
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* Corresponding author
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Word Count: 570
ACCEPTED MANUSCRIPT Abstract A 58-year-old male underwent ambulatory ECG monitoring with continuous patch monitoring (Zio XT Patch) for the complaint of episodic dyspnea. In the period of monitoring the patient
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suffered sudden cardiac death (SCD) with continuous ECG recording showing pronounced ST
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segment elevations followed by bradycardia and death. This report highlights the growing potential of continuous ST segment monitoring, and features the infrequent entity of ischemic
SC
electromechanical dissociation with bradyarrhythmia as a cause of SCD.
Keywords
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ambulatory ECG, sudden cardiac death Case Presentation
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A 58-year-old man was referred for ambulatory ECG monitoring to evaluate the complaint of episodic dyspnea with concern for arrhythmic etiology, for which a continuously recording ECG monitoring patch (Zio XT Patch) [iRhythm Technologies, San Francisco, California] was placed
ED
providing 2 weeks of monitoring. His history included hypertension, left ventricular hypertrophy, heart failure with preserved ejection fraction, and chronic kidney disease. He underwent coronary angiography three months prior without evidence of significant obstruction. Three days
PT
after placement of the monitor the patient suffered an unwitnessed sudden cardiac death (SCD), the clinical circumstances of which were unknown- but was captured on continuous monitoring
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which was submitted post mortem for analysis.
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The single-lead ECG recorded a patient triggered event corresponding to normal sinus rhythm, and one episode of ventricular tachycardia (VT) lasting 8 beats with a maximum rate of 176 bmp (Figure 1A) occurring twenty-two hours prior to asystole. Compared to baseline (Figure 1B) and twenty-nine minutes prior to asystole, the patient abruptly developed upward-sloping ST segments associated with sinus arrest and junctional escape rhythm (Figure 1C). Twenty-four minutes prior to asystole he developed pronounced and progressive convex ST segment elevations with degradation to ventricular escape and subsequent bradycardia (Figure 1D). This followed by further widening of the QRS with development of RsR’ complexes, followed by agonal QRS complexes and terminal asystole. (Figure 1E).
The importance of this case are twofold. Firstly, there are currently no accepted criteria for continuous ST segment monitoring on patch monitoring of this type and these devices do not carry approval for such an indication. As these devices continue to advance in technology, the
ACCEPTED MANUSCRIPT development of ischemic criteria may promote the possibility for real-time remote monitoring and algorithm triggered patient warnings. Recently a single-lead intracardiac ST segment monitoring device, the Angelmed Guardian device [Angel Medical Systems, Tinton Falls, New
T
Jersey] showed promise in a small clinical trial where use resulted in more rapid presentation to
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care compared to historical controls in a small population with acute coronary syndrome.1 The Guardian device is approved for clinical use in Brazil, and a confirmatory multicenter trial is
SC
ongoing in the United States.
Secondly, this case highlights the infrequent entity of ischemic electromechanical dissociation
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as a cause of SCD. In contrast to VT and ventricular fibrillation which represents the majority of such cases, bradyarrhythmic death makes up as little as 16% of SCD observed on ambulatory
MA
monitoring.2
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References:
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1. Fischell DR, Fischell TA, Avezum A, et al. Initial clinical results using intracardiac electrogram monitoring to detect and alert patients during coronary plaque rupture and ischemia. J Am Coll
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Cardiol. 2010;56(14):1089-1098.
2. Bayés de Luna A, Coumel P, Leclercq JF. Ambulatory sudden cardiac death: Mechanisms of
AC
production of fatal arrhythmia on the basis of data from 157 cases. Am Heart J. 1989;117(1):151-159.
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CE
PT
ED
MA
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SC
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ACCEPTED MANUSCRIPT
Figure 1
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Highlights ● In contrast to ventricular fibrillation and ventricular tachycardia, bradyarrhythmias are responsible for a minority of sudden cardiac deaths. ● Ambulatory ST segment monitoring has shown potential for more rapid presentation in setting of acute ischemia. ● There are currently no validated criteria for ST segment monitoring with patch monitoring (Zio XT).
S0022-0736(17)30419-3 doi: 10.1016/j.jelectrocard.2017.10.010 YJELC 52525
To appear in:
Journal of Electrocardiology
Please cite this article as: Simpson Timothy F., Goldschlager Nora, Sudden Cardiac Death Preceded by ST Segment Elevations During ECG Patch Monitoring, Journal of Electrocardiology (2017), doi: 10.1016/j.jelectrocard.2017.10.010
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
T
Sudden Cardiac Death Preceded by ST Segment Elevations During ECG Patch Monitoring
RI P
Timothy F Simpson, MD, Pharm.Da*, Nora Goldschlager MDb A.Department of Medicine, University of California San Francisco, San Francisco, California.
SC
B. Division of Cardiology, Department of Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California.
NU
* Corresponding author
AC
CE
PT
ED
MA
Word Count: 570
ACCEPTED MANUSCRIPT Abstract A 58-year-old male underwent ambulatory ECG monitoring with continuous patch monitoring (Zio XT Patch) for the complaint of episodic dyspnea. In the period of monitoring the patient
T
suffered sudden cardiac death (SCD) with continuous ECG recording showing pronounced ST
RI P
segment elevations followed by bradycardia and death. This report highlights the growing potential of continuous ST segment monitoring, and features the infrequent entity of ischemic
SC
electromechanical dissociation with bradyarrhythmia as a cause of SCD.
Keywords
NU
ambulatory ECG, sudden cardiac death Case Presentation
MA
A 58-year-old man was referred for ambulatory ECG monitoring to evaluate the complaint of episodic dyspnea with concern for arrhythmic etiology, for which a continuously recording ECG monitoring patch (Zio XT Patch) [iRhythm Technologies, San Francisco, California] was placed
ED
providing 2 weeks of monitoring. His history included hypertension, left ventricular hypertrophy, heart failure with preserved ejection fraction, and chronic kidney disease. He underwent coronary angiography three months prior without evidence of significant obstruction. Three days
PT
after placement of the monitor the patient suffered an unwitnessed sudden cardiac death (SCD), the clinical circumstances of which were unknown- but was captured on continuous monitoring
CE
which was submitted post mortem for analysis.
AC
The single-lead ECG recorded a patient triggered event corresponding to normal sinus rhythm, and one episode of ventricular tachycardia (VT) lasting 8 beats with a maximum rate of 176 bmp (Figure 1A) occurring twenty-two hours prior to asystole. Compared to baseline (Figure 1B) and twenty-nine minutes prior to asystole, the patient abruptly developed upward-sloping ST segments associated with sinus arrest and junctional escape rhythm (Figure 1C). Twenty-four minutes prior to asystole he developed pronounced and progressive convex ST segment elevations with degradation to ventricular escape and subsequent bradycardia (Figure 1D). This followed by further widening of the QRS with development of RsR’ complexes, followed by agonal QRS complexes and terminal asystole. (Figure 1E).
The importance of this case are twofold. Firstly, there are currently no accepted criteria for continuous ST segment monitoring on patch monitoring of this type and these devices do not carry approval for such an indication. As these devices continue to advance in technology, the
ACCEPTED MANUSCRIPT development of ischemic criteria may promote the possibility for real-time remote monitoring and algorithm triggered patient warnings. Recently a single-lead intracardiac ST segment monitoring device, the Angelmed Guardian device [Angel Medical Systems, Tinton Falls, New
T
Jersey] showed promise in a small clinical trial where use resulted in more rapid presentation to
RI P
care compared to historical controls in a small population with acute coronary syndrome.1 The Guardian device is approved for clinical use in Brazil, and a confirmatory multicenter trial is
SC
ongoing in the United States.
Secondly, this case highlights the infrequent entity of ischemic electromechanical dissociation
NU
as a cause of SCD. In contrast to VT and ventricular fibrillation which represents the majority of such cases, bradyarrhythmic death makes up as little as 16% of SCD observed on ambulatory
MA
monitoring.2
ED
References:
PT
1. Fischell DR, Fischell TA, Avezum A, et al. Initial clinical results using intracardiac electrogram monitoring to detect and alert patients during coronary plaque rupture and ischemia. J Am Coll
CE
Cardiol. 2010;56(14):1089-1098.
2. Bayés de Luna A, Coumel P, Leclercq JF. Ambulatory sudden cardiac death: Mechanisms of
AC
production of fatal arrhythmia on the basis of data from 157 cases. Am Heart J. 1989;117(1):151-159.
AC
CE
PT
ED
MA
NU
SC
RI P
T
ACCEPTED MANUSCRIPT
Figure 1
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CE
PT
ED
MA
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SC
RI P
T
Highlights ● In contrast to ventricular fibrillation and ventricular tachycardia, bradyarrhythmias are responsible for a minority of sudden cardiac deaths. ● Ambulatory ST segment monitoring has shown potential for more rapid presentation in setting of acute ischemia. ● There are currently no validated criteria for ST segment monitoring with patch monitoring (Zio XT).