[SCD-FORUM] 1E. Dr. Cannom's case. Dr. Li Zhang

[SCD Symposium]

亲爱的Dr. Cannom：
非常感谢您提供您病例中患者的心电图。在12导联心 
电图中，除了V1-2之外，都可以看到明显的Osborn（或J 
点）波。ST段轻度抬高。QT间期正常。这种情况可以 
在早期复极综合症中出现。在这个特别的案例中，我 
怀疑，这个Osborn波是不是由于慢性冠状动脉阻塞造成 
的左室一些部分传导延迟的标志，并且成为室性快速 
性心律失常反复发作的病理基础。如果这个假设是真 
的，他就有VT/VF的高度危险。

您是这个领域的专家，而且您对患者很了解。我希望 
能在SCD研讨会中向您和其他专家学习。

真诚地，

*** http://www.scd-symposium.org/files/Cannom.pdf

Li Zhang, MD
  LDS Hospital, Intermountain Healthcare
  University of Utah School of Medicine
  Salt Lake City, UT
  USA


临床病例
David S. Cannom, M.D.

患者是一名57岁的高加索男性，既往健康且活跃。2005 
年3月2日他在一次应激试验中，出现了右束支形态的 
室性早搏，且早搏在活动后被抑制。这些室性期前收 
缩是落在T波上的。经历了长时间骑自行车和紧张活 
动的周末之后，在2005年11月28日他去上班了，感觉也 
不错，但是在中午他就出现了一次发作，他的同事为 
他进行了CPR。参数提示他出现了室性心动过速，在电 
击之后转为窦律。插管之后，他很快苏醒了。造影提 
示对角支阻塞，但肌钙蛋白没有明显升高。所以很难 
明确对角支的阻塞是慢性的还是急性的。他冠状动脉 
的损伤为20-40%，这种病变通常认为是比较轻的。 
LVEF60%，收缩功能正常。随后患者植入了Medtronic的 
ICD。他每天服用立普妥20mg，没有服用他心脏骤停时 
所用的ASA。他的胆固醇是223，HDL是78，LDL是111（mg/ 
ml）。

随后患者一直比较好。他是一个自行车爱好者，事实 
上在2005年7月和2006年7月（在他心脏停搏之后）他毫 
无困难地参加了环法自行车赛的山地赛段。而且在 
2006年7月参加环法自行车赛之前，他还出现过一系列 
ICD的电击，那是在周末经过了一个长时间非常紧张的 
自行车比赛之后，当他在家里睡觉时出现的。之后装 
置提示当时有多形性的室性心动过速。他没有用β受 
体阻滞剂，也没有检测电解质。

患者有前列腺癌病史，并已经在2004年2月行手术治 
疗。他的父亲又冠心病病史，曾接受过搭桥手术，现 
在85岁仍健在。他的母亲有慢性阻塞性肺部疾病，在 
75岁那年去世。他有一个健康的姐姐。没有家族性猝 
死的病史。

他曾经吸烟5年，1972年时戒烟。他是一个律师，工作 
压力非常大。

经检查，患者的血压是128/76mmHg，脉搏60bpm且规则。体 
重是164磅。肺部听诊叩诊均正常。心律齐且心音正 
常。腹部平软，没有脏器肿大。周围静脉搏动是4/4。

该患者现在求助于电生理专家，咨询预后和活动强度 
的问题。目前他每周都骑车上山。


问题：
1）  心脏骤停可能的病因是什么？还需要哪些进一步 
的检查？

2）  在他最近ICD的电击之后，如果有药物，他需要吃 
吗？

3）  对于他骑车有什么建议应该告诉他？

4）  对于驾驶呢？



Dear Dr. Cannom:
    Thank you so much for providing the ECG*** of your case patient  
upon my
  request.

*** http://www.scd-symposium.org/files/Cannom.pdf

 From this ECG I noticed a prominent Osborn (or J) wave in most
  of 12 leads except V1-2. The ST segment is slightly elevated. The QT
  interval is normal. Such pattern may be seen in early repolarization
  syndrome. In this particular case, I wonder whether this Osborn  
wave is
  an indication of delayed conduction in some part of left ventricle due
  to chronic coronary insufficiency, and therefore a substrate to
  reentrant ventricular tachyarrhythmias. If this assumption were  
true, he
  is under a high risk of VT/VF.
    You are the leading expert in this area, and you know much more  
about
  this patient. I look forward to learning from you and from other  
experts
  in this SCD-symposium.
  Sincerely,

  Li Zhang, MD
  LDS Hospital, Intermountain Healthcare
  University of Utah School of Medicine
  Salt Lake City, UT
  USA

Clinical Cases

  The patient is a 57-year-old previously healthy and very active
  Caucasian male

  David S. Cannom, M.D.

  CASE
  The patient is a 57-year-old previously healthy and very active
  Caucasian male.  He had a stress test on 3/2/05 and on this had PVC's
  with a right bundle branch morphology which suppressed with exercise.
  These PVC's were on the T wave.  On 11/28/05 he went to work feeling
  well after a long weekend of biking and other strenuous activity,  
but at
  noon he had a seizure and CPR was initiated by a colleague.  The
  paramedics found him to be in ventricular tachycardia and he was  
shocked
  back to sinus rhythm.  He was intubated and quickly recovered.  At
  catheterization he had an occluded diagonal which filled via  
collaterals
  but no significant troponin elevation.  It is unclear whether the
  diagonal occlusion was chronic or acute.  He had lesions in his  
coronary
  arteries of 20-40% but these were considered minor.  The LVEF was 60%
  with normal contractility.  The patient subsequently had a  
Medtronic ICD
  implanted.  He was taking Lipitor 20 mg per day but not ASA at the  
time
  of his cardiac arrest.  His cholesterol was 223, HDL 78, LDL 111mg%.

  The patient subsequently did well.  He is an avid bicycle rider  
and, in
  fact, went to Europe in July 2005 and in July 2006 (the latter  
after his
  cardiac arrest) where he participated in portions of many mountain
  stages of the Tour de France without difficulty.  Also in July 2006
  prior to his participation in the Tour de France, while asleep at home
  after a long weekend of very strenuous biking activity and heavy fluid
  intake of diet drinks, he had a series of ICD shocks that upon device
  interrogation showed polymorphic ventricular tachycardia.  He has not
  been on a beta blocker.  He did not have his electrolytes checked.

  The patient has a history of prostate cancer which was treated
  surgically in February, 2004.  His father had a history of coronary
  disease and underwent a bypass procedure but is alive at age 85.  His
  mother had chronic obstructive pulmonary disease and died at age  
75.  He
  has a healthy sister.  There is no family history of sudden death.

  He smoked for 5 years but quit in 1972.  He works as an attorney  
and is
  under significant stress.

  On examination the patient's blood pressure is 128/76 and the pulse is
  60 and regular.  His weight is 164 pounds.  He has no jugular venous
  distention and full carotids.  His lung fields are clear to percussion
  and auscultation.  He has a normal cardiac rhythm with a normal first
  and second heart sound.  His abdomen is soft and flat without
  organomegaly.  The peripheral pulses are 4/4.

  The patient now comes to his electrophysiologist for advice about his
  prognosis and level of activity.  He currently bikes in hills each
  weekend.



  QUESTIONS

  1) What were the possible causes of his cardiac arrest?  -  Is further
  testing warranted?

  2) After his recent ICD shocks, what medicines, if any, should he be
  taking?

  3) What advice should be given about his bicycle riding?

  4) What about automobile driving?